EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version).

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

Complications following ultrasound-guided thoracocentesis.

PURPOSE: To retrospectively register the number and type of complications following ultrasound-guided thoracocentesis, and to evaluate the need for routine chest X-ray after the procedure. MATERIAL AND METHODS: Complications were retrospectively registered from the radiological and clinical reports of 371 consecutive patients who had undergone thoracocentesis with a total of 711 procedures. RESULTS: The mean volume evacuated was 823ml (range 0-3600ml). Twenty (2.8%) pneumothoraces were found after 711 thoracocenteses, but in no case was chest tube drainage necessary. Hemoptysis occurred in one patient. CONCLUSION: Ultrasound-guided thoracocentesis was found to be a safe procedure. Based on these results, no reason was found to introduce an upper limit of the amount of fluid drained in one session. Routine follow-up chest X-ray is not justified in the absence of clinical symptoms.

Multicenter evaluation of a new laser guidance system for computed tomography intervention.

PURPOSE: To measure the accuracy of laser-guided punctures and to evaluate the usefulness of the developed laser-guided system. MATERIAL AND METHODS: The study included 67 patients referred for computed-tomography-guided puncture. The majority of the punctured lesions were located in the chest (28 patients) or abdomen (19 patients). The mean diameter of the lesion was 3.1 cm, and the mean path length was 6.8 cm. The laser guide was movable along a horizontal or vertical rail and not physically connected to the CT unit. The angle of insertion was entered manually into the display of the unit by the interventional radiologist. A prospective multicenter trial was carried out. RESULTS: A mean of 1.1 needle passes were necessary to reach the target, and in 55 (84.6%) of the patients the target was reached on the first needle pass. The mean deviation of the needle from the preselected angle was 1.8 degrees. The mean targeting time (from the initial localizing scan until the needle was in the target) was 15.6 min. In every case, both the usefulness and the ease of use of the laser guidance system were subjectively evaluated on a 5-point scale; the mean usefulness score was 4.5, while the mean ease of use score was 4.7. CONCLUSION: Different users at four different centers found the laser guidance system useful and easy to use. A high level of accuracy of the puncture angle was obtained in most cases.

Doppler examination of the allografted kidney.

A comprehensive ultrasound examination of the transplanted kidney includes a Doppler examination. Duplex Doppler, color Doppler and power Doppler can all reveal important information. In addition, calculation of the resistance and pulsatility indices to quantify changes in the spectral Doppler waveform can be of great help, particularly in the first weeks and months following a transplantation. The Doppler part of the examination should evaluate the vessels to and from the transplant, as well as the parenchyma with calculations of indices to detect the presence of increased vascular resistance. The conclusions drawn from the Doppler-derived information combined with the results from gray-scale scanning and clinical information will very often be of clinical significance for the handling of the patient.

Kidney function and glomerulopathy over 8 years in young patients with Type I (insulin-dependent) diabetes mellitus and microalbuminuria.

AIMS/HYPOTHESIS: We aimed to investigate prospectively the interrelation between kidney function and glomerular morphological changes over 8 years in young patients with Type I (insulin-dependent) diabetes mellitus and microalbuminuria. METHODS: Kidney biopsies were taken at baseline and after 8 years in 18 subjects who were 20 years of age (19-29 mean and range), had duration of diabetes for 11 years (7-18), and who had an albumin excretion rate of 45 microg/min (15-194). The glomerular ultrastructural parameters were analysed using stereological methods. RESULTS: At the end of the study three patients had an increased albumin excretion rate of more than 25 % a year, two of whom developed overt nephropathy. Glomerular filtration rate declined 2.3 ml/min x 1.73 m(-2) x yr(-1). Glomerular volume, volume fractions of matrix and mesangium, and basement membrane thickness showed an increase over the 8 years. Multiple regression analysis showed that mean 8-years HbA(1 c), matrix volume fraction(baseline) and basement membrane thickness BMT(baseline) accounted for 70 % of the variation in AER at the end of the study. Mesangial volume fraction(baseline,) glomerular filtration fraction(baseline,) and mean 8-year HbA(1 c) accounted for 73 % of the change in glomerular filtration rate from baseline. Smoking was strongly associated with the glomerular filtration rate at baseline ( r = 0.65). When glomerular filtration rate(baseline) was omitted from the equation, smoking was the only significant parameter linked to the change in glomerular filtration rate from the baseline. CONCLUSION/INTERPRETATION: In patients who had diabetes for 20 years, long-term hyperglycaemia and glomerulopathy found 8 years prior to the study, and possibly smoking, affected renal function (i. e. albumin excretion rate and glomerular filtration rate).

[Voiding problems and urinary tract complications in adolescents and adults with myelomeningocele]. / Vannlatingsproblemer og urinveiskomplikasjoner hos ungdom og voksne med myelomeningocele.

BACKGROUND: The aim of this study was to describe voiding dysfunction and urinary tract complications in a population above 16 years of age with myelomeningocele. MATERIAL AND METHODS: 51 persons were included in the study. Data were obtained by questionnaires, ultrasound and glomerular filtration rate; in those with intact urinary bladder, by cystometry and videocystography. RESULTS: 30 out of 33 persons with intact urinary bladder were incontinent. Those with daily incontinence described this as a major problem. Cystometry concluded with normal detrusor contractions in three, detrusor hyperreflexia in five, and a detrusor hyporeflexia in 25 persons. Three out of 30 had vesicoureteral reflux. Ultrasound showed mild hydronephrosis and/or scarring in three persons. Average glomerular filtration rate was 86% (50-131%). 11 had Bricker diversion and seven continent reservoirs. 15 out of 18 persons with urinary diversion were satisfied with this solution. In persons with urinary diversion, the average glomerular filtration rate was 78% (44-109%). Ultrasound showed hydronephrosis and/or scarring in seven out of 16. Overall, urinary tract infections last year were reported by 56%, and pyelonephritis was more common in those with urinary diversion. INTERPRETATION: Incontinence is a common problem in adults with myelomeningocele. About one third had upper urinary tract changes, but none had renal failure.

[Follow up of urinary tract problems in adults with myelomeningocele]. / Oppfølging av urinveisproblemer hos voksne med myelomeningocele.

BACKGROUND: More than 90% of persons with myelomeningocele have a neurogenic bladder disturbance with incontinence and risk of upper urinary tract deterioration. Both aspects need to be considered when planning treatment and follow-up. MATERIAL AND METHODS: The study is based on review of articles and clinical experience. RESULTS: A thorough examination of the patient's voiding methods and incontinence is necessary. Examinations for renal function, reflux and hydroureteronephrosis as well as cystometry should also be carried out. The results of such examinations, together with an assessment of the patient's motor and cognitive function, as well as motivation, will provide a basis for further treatment and follow-up. We suggest a flow-chart for treatment and follow-up of persons above 16 years of age with myelomeningocele. INTERPRETATION: Patients with myelomeningocele should have a thorough examination and an individual plan for treatment and follow-up of their urinary tract dysfunction. Depending on the pathological findings, routine follow-up should be in done intervals from six months to five years.

Uveal melanomas with optic nerve extension: report of two cases diagnosed by transvitreal biopsy, one of them with a multicentric tumour.

PURPOSE: To report two cases of invasive uveal melanomas, one of which showed multifocality. METHODS: Clinical examination, ultrasonography, colour Doppler analysis, cytological and histopathological evaluations. RESULTS: Transvitreal biopsy (case 1) or fine needle aspiration biopsy (FNAB) (case 2) revealed malignant melanomas in both patients. Light microscopy and immunohistochemical examinations substantiated the diagnosis of mixed cell type melanomas. In addition, one patient had a multifocal melanoma with papilloedema and colour Doppler findings suggestive of optic disc involvement. CONCLUSION: Transvitreal biopsy for histology or cytology is a reliable procedure to obtain an accurate diagnosis without delay of a lesion adjacent to the optic nerve head. In our two cases the biopsy findings led to enucleation.

Contrast-enhanced ultrasound Doppler examination of the retrobulbar arteries.

PURPOSE: To evaluate the diagnostic usefulness of an ultrasound contrast agent in examination of the retrobulbar arteries. MATERIAL AND METHODS: Ten healthy volunteers received a galactose-based echo-contrast medium (Levovist) by i.v. infusion. The ophthalmic, central retinal, the nasal and the temporal posterior ciliary arteries and the short ciliary arteries were studied in 19 eyes by color and spectral Doppler ultrasonography before and after contrast administration. Peak systolic and end diastolic velocities and spectral Doppler indices (pulsatility and resistive) were assessed. The quality of the spectral and color Doppler imaging of the arteries were visually graded on a 5-point scale. RESULTS: There were significant differences in pre- and post-contrast peak systolic velocities in the ophthalmic arteries (p<0.05), but not in the other retrobulbar arteries, or in any of the spectral Doppler indices. After contrast administration the mean spectral Doppler score for vessels poorly visualized before contrast increased from 2.2 (+/-0.4) to 3.1 (+/-0.9). The number of short ciliary arteries with sufficient spectral Doppler quality increased from 7 prior to contrast to 14 following contrast. Prior to the infusion of Levovist, 62 (73%) out of 85 retrobulbar arteries could be evaluated with a sufficient spectral Doppler quality. Following the administration of contrast 66 (78%) arteries had sufficient spectral Doppler quality. However, by combining the results of the pre- and post-contrast examinations, sufficient spectral Doppler quality was obtained in 77 (91%) of the 85 retrobulbar arteries. CONCLUSION: Contrast enhancement increased the number of detectable retrobulbar vessels. However, in the case of good quality pre-contrast imaging of the retrobulbar vessels, the use of Levovist did not add any substantial diagnostic information. The optimal spectral Doppler results were obtained when both pre- and post-contrast examinations were performed.

[How is the specialist training in radiology?]. / Hvordan er det å vaere utdanningskandidat i radiologi?

BACKGROUND: On the basis of results from a focus group interview showing that the specialist training in radiology was considered unsatisfactory, we performed a questionnaire survey among residents attending specialist training in Norwegian x-ray departments. MATERIAL AND METHODS: A questionnaire on background and working and study conditions was mailed to 113 radiology residents. RESULTS: The response rate was 73%. More than 50% of the residents reported that the quality of the training they received in magnetic resonance imaging and to some extent in interventional radiology and doppler examinations, was unsatisfactory, independent of type of department. Residents working in larger departments reported more problems in learning the most common interventional procedures, CT examinations and fluoroscopy examinations than did collegues working in smaller departments. Experienced autonomy with regard to organisation of own work was significantly lower among female physicians than among their male collegues. INTERPRETATION: There is shortage of time as well as specific learning possibilities for Norwegian radiology residents. The potential for improvement is large.

[Initial experiences with a new optical target system (SimpliCT) for CT-guided punctures]. / Erste Erfahrungen mit einem neuen optischen Zielsystem (SimpliCT) für CT-gesteuerte Punktionen.

PURPOSE: To evaluate the prototype of a new optical target device for CT-guided punctures and interventions. METHODS: An optical target device for CT-guided punctures was applied in 24 interventions. The system consists of a laser target device mounted on a stand. The biopsy needle is adjusted according the course of a laser beam. The target angle has to be adjusted on the laser unit. The laser carrier can be moved along an 90 degrees-angled rail, allowing punctures from any angle in plane. Furthermore, angulation in the z-plane is possible, supporting interventions with gantry tilt. Size and depth of the target lesions, the planned and the actual angle of the inserted needle, the numbers of corrections of the needle position, and the time required for the puncture were evaluated. The user rated the benefit of the system and the ease of the application. RESULTS: All 24 interventions were carried out successfully. The mean difference between the planned and the actual angle of the needle was 1.3 degrees (SD: 0.7 degree). The system was considered as easy to handle and as a valuable aid. CONCLUSIONS: The laser target device is a simple navigation system which allows accurate positioning of a needle. Requiring an acceptable low preparation time, it easily can be integrated into the procedure.

Testicular microlithiasis--a possibly premalignant condition. Report of five cases and a review of the literature.

Testicular microlithiasis (TM) is a rare condition characterized by the presence of multiple small intratesticular calcifications. The etiology is unknown but the condition has been observed in a variety of different urological conditions. We report on 5 cases diagnosed by ultrasonography at our departments from 1992 to 1994. A review of the literature plus our present 5 cases gives a total of 124 reported cases of TM. TM was associated with testicular malignancy in 44 patients (35%) of whom 24 (19%) had a seminoma and 20 (16%) a non-seminoma. There were 4 reports of testicular malignancy developing in patients with a prior diagnosis of TM. The condition should be considered premalignant and a careful follow-up of TM patients is advocated.

[Abdominal tuberculosis and amebic abscess. Simultaneous diagnosis of 2 rare infections of same localization]. / Abdominal tuberkulose og amøbeabscess. Samtidig påvisning av to sjeldne infeksjoner med samme lokalisasjon.

A 26-year-old Indian male was admitted to hospital with loss of weight and vague abdominal pain of several weeks duration. Ultrasonography and computed tomography showed several expansive lesions near the pancreatic head, probably representing enlarged lymph nodes. A few milliliters of yellowish pus were aspirated by ultrasound guided aspiration. Microscopic examination of the pus showed trophozoits, and Mycobacterium tuberculosis subsequently grew from the pus culture. Abdominal tuberculosis is a rare condition, particularly in the pancreas and the peripancreatic region. The report stresses the importance of considering the possible coexistence of more than one infectious disease in patients from endemic areas.

Adrenal cortical carcinoma in Norway, 1970-1984.

Adrenal cortical carcinoma is a rare and highly malignant tumor. This retrospective study includes 99 patients (57 males and 42 females) reported to The Cancer Registry of Norway during the 15 year period from 1970 to 1984. The age adjusted incidence was 1.5 per million per year. Eighty-one patients were diagnosed with adrenal cortical carcinoma when still alive. In 18 cases the diagnosis was first made at autopsy. Median age at diagnosis was 54 years (range 2-88 years) with a slight male predominance. Information about initial symptoms was available in 67 patients, of whom 26 patients (18 females and 8 males) presented with clinically functioning tumors, the Cushing syndrome and virilization being most frequently encountered. Only 28 (35%) of 81 patients diagnosed when still alive had tumors confined to the adrenals. Half of the patients had distant metastases, with lungs and liver being the most frequent sites. Sixty-one patients underwent surgery; 51 patients had a radical or debulking operation and 10 patients had laparotomy with tumor biopsy. After a complete follow-up for at least 6 years (range 6-21 years), only 9 patients were still alive. Early stage (Stage I and II) and curative resection had a significant impact on the outcome of this disease. To improve prognosis, early diagnosis and radical surgery, if feasible, are needed.

[Percutaneous gallbladder drainage in acute cholecystitis]. / Perkutan galleblaeredrenasje ved akutt kolecystitt.

12 high-risk patients underwent percutaneous cholecystostomy for serious acute cholecystitis using a transhepatic approach under ultrasonic guidance. Eight patients had acute acalculous cholecystitis, and four had acute calculous cholecystitis. Following the drainage procedure a mean decrease in body temperature of 0.7 degrees centigrade was noted in 11 patients and a reduction of pain and defence in five out of nine patients. Two patients had a perforated gallbladder and pericholecystic abscess; both cases were successfully treated by percutaneous drainage. Four patients with acute acalculous cholecystitis died while in hospital for reasons unrelated to the procedure. The catheter became dislodged in three patients.

Ultrasonically guided percutaneous drainage of breast abscesses.

Four patients with breast abscesses developed during lactation were successfully treated by ultrasonically guided percutaneous drainage under local anaesthesia. Three patients continued nursing during and after the period of treatment and 2 patients were treated as out-patients. The cosmetic results were excellent. No recurrence of abscess was observed following the treatment. Ultrasonically guided percutaneous drainage as an alternative to surgery is discussed.

[Ultrasonic diagnosis of deep venous thrombosis. A comparison with venography]. / Ultralyddiagnostikk ved dyp venetrombose. En sammenlikning med venografi.

In a prospective study ultrasonography (US) was compared with venography for diagnosis of deep venous thrombosis of the leg. Using venography, thrombosis was demonstrated in 25 patients. Based on two criteria, non-compressible vein and intraluminal echoes, US showed thrombosis in 23 patients, i.e. the sensitivity was 92%. Isolated calf vein thrombosis was demonstrated in 2 out of 4 patients. In 18% of the patients with negative venography other pathological conditions were demonstrated by US, (i.e. Baker's cysts, calf vein hematomas and superficial calf vein thrombosis) which could explain the clinical condition. Venography is a somewhat costly procedure. The cost of films and non-ionic contrast medium is approximately NOK 400, while the cost of film for US examination is about NOK 10.